Provider Demographics
NPI:1083697965
Name:COOK, FREDERICK G (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:G
Last Name:COOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 3RD ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4007
Mailing Address - Country:US
Mailing Address - Phone:503-588-3600
Mailing Address - Fax:503-363-3891
Practice Address - Street 1:5050 SKYLINE VILLAGE LOOP S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9490
Practice Address - Country:US
Practice Address - Phone:503-391-1110
Practice Address - Fax:503-370-4237
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR233585Medicaid
OR233585Medicaid
08WCJXMCMedicare ID - Type Unspecified